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Chapter 36 - Child Maltreatment

Part 3 - Professional Services

Title Section
Introduction 3-36.1
Purpose 3-36.1A
Scope 3-36.1B
Background 3-36.1C
Policy 3-36.1D
Authorities 3-36.1E
Definitions 3-36.1F
Responsibilities 3-36.2
Chief Medical Officer 3-36.2A
National Forensic Nurse Consultant/Coordinator 3-36.2B
Area Chief Medical Officer 3-36.2C
Chief Executive Officer 3-36.2D
Facility Medical/Clinical Director/Chief Medical Officer (CMO) 3-36.2E
Facility Chief Nursing Officier/Director of Nursing 3-36.2F
Service Unit Behavioral Health Surpervisor 3-36.2G
Clinical Staff 3-36.2H
Clearance to Work with Children 3-36.3
Chaperones 3-36.4
Reporting 3-36.5
Reporting Requirements 3-36.5A
Federal Law Requirements 3-36.5B
Legal Consultation 3-36.5C
Health Records, Use of Information, and Confidentiality 3-36.6
Health Records 3-36.6A
Use of Medical Information 3-36.6B
Confidentiality 3-36.6C
Consultation for Disclosure 3-36.6D
Informed Consent 3-36.7
Informed Consent 3-36.7A
Waiver of Parental Consent 3-36.7B
Minors 3-36.7C
Components of Care for Child Maltreatment 3-36.8
Entry into the Health Care System 3-36.8A
Consent for Care 3-36.8B
Examination 3-36.8C
Evidence 3-36.8D
Sexually Transmitted Infections (STI) and HIV 3-36.8E
Alchohol and Drugs 3-36.8F
Discharge Planning and Referral 3-36.8G
Documentation 3-36.8H
Training, Privileging and Competencies 3-36.9
Training 3-36.9A
Privileging 3-36.9B
Competencies for Registered Nurses in the PSAE Role 3-36.9C
Quality Improvement 3-36.10
Responding to a Subpoena 3-36.11


  1. Purpose. The purpose of this chapter is to establish the requirements for identifying and responding to suspected child maltreatment (CM).
  2. Scope. The scope of this chapter establishes clinical care guidelines for patients under the age of 18 presenting for services at Indian Health Service (IHS) hospitals, youth regional treatment centers, health centers, and health stations (hereafter referred to as facilities) for the identification, evaluation, and management of suspected CM.

    NOTE: Adolescents are distinguished from prepubertal children as they have reached Tanner Stage 3 and above with potential reproductive capability. For the purpose of examination, adolescents presenting following sexual assault/abuse, refer to Indian Health Manual (IHM) Part 3, Chapter 29 - Sexual Assault for the medical forensic exam.

  3. Background. This chapter was developed in response to the significant morbidity and mortality associated with CM among American Indian and Alaska Native (AI/AN) children. As for all aspects of abuse and neglect, child maltreatment is grossly under-reported and thus is critical to identify for the health and well-being of children.

    Child maltreatment, a term that encompasses all forms of abuse and neglect, is associated with injuries, delayed physical growth, neurological damage, and death. Child maltreatment is linked with psychological and emotional problems such as aggression, depression, anxiety, low self-esteem, and post-traumatic stress disorder as well as an increased risk for the development of health problems later in life.

    For these reasons, CM requires a comprehensive approach that integrates health care within a collaborative community response. Health care professionals work to address CM through assessment, treatment, education, and prevention with community stakeholders in order to maximize patient and family support and healing.

  4. Policy. It is the policy of the IHS that:
    1. Patients under the age of 18 presenting with suspicion of CM receive care, either onsite or by referral, that is: timely; patient-centered; trauma-informed; developmentally, linguistically, and culturally appropriate for children; and intended to reduce the potential effects of trauma;
    2. Medical forensic examinations are provided by trained examiners;
    3. Health care facilities will address instances where the person accompanying the child is the suspected offender, in collusion with the offender or otherwise is believed to be contributing to the abuse of the child, and assess risk for human trafficking;
    4. Patients suspected of CM will receive medically appropriate evaluation, testing, and treatment considering the most current recommended guidelines, including, but not limited to:
      • American Academy of Pediatrics Committee on Child Abuse and Neglect
      • Department of Justice National Protocol for Sexual Abuse Medical Forensic Examinations - Pediatric
      • Department of Justice National Training Standards for Sexual Assault Medical Forensic Examinations
      • CDC Sexually Transmitted Diseases Treatment Guidelines;
    5. All facilities develop policies and procedures consistent with this chapter; and
    6. All facilities participate in a coordinated community response, such as a multidisciplinary team, with local child welfare agencies, hospitals, schools, and other community-based organizations focused on collaborative efforts to address and eliminate CM.
  5. Authorities.
    1. Indian Health Care Improvement Act, 25 United States Code (U.S.C.) §§ 1601-1683
    2. Indian Child Protection and Family Violence Prevention Act, 25 U.S.C. § 3201 et seq; 42 CFR §§ 136.401-136.418
    3. Reporting of Child Abuse, 18 U.S.C. § 1169
    4. Victims of Child Abuse Act, 34 U.S.C. § 20301 et seq.
    5. Victims of Child Abuse Act, 34 U.S.C. § 20341, Child Abuse reporting.
    6. Child Abuse Prevention and Treatment Act (CAPTA) 42 U.S.C. § 5101 et seq.
    7. Offenses committed within Indian Country, 18 U.S.C. § 1153
    8. Emergency Medical Treatment and Active Labor Act (EMTALA), 42 U.S.C. § 1395dd
  6. Definitions.
    1. Chain of Custody. Chain of custody is the preservation of physical evidence from the time of its collection until its presentation at trial that ensures no tampering or contamination has occurred. The chain of custody requires that every transfer of evidence from person to person be documented to demonstrate that no unauthorized individual had access to the evidence. The transfer of evidence must be kept to a minimum.

      NOTE: The Regional Office of the General Counsel (OGC) may provide further guidance on chain of custody procedures.

    2. Chaperone. A member of staff who has a favorably adjudicated background investigation as required under 25 U.S.C. § 3207 and 34 U.S.C. § 20351, and who attends a medical procedure or exam as a safeguard and witness, for both the child and the health care provider.
    3. Child. A child, for the purposes of this policy, is a person under the age of 18 years old who is not legally emancipated.
    4. Child Maltreatment. Child maltreatment is an act or failure to act which results in or presents a risk of death, physical injury, emotional harm, sexual abuse/exploitation of a child including human trafficking and child pornography. Legal definitions of maltreatment vary in federal and state laws.

      Four types of CM are generally recognized:

      1. Physical Abuse. Physical abuse is non-accidental physical injury (ranging from minor bruises to fractures or death) as a result of punching, beating, kicking, biting, shaking, throwing, stabbing, choking, hitting (with a hand, stick, strap, or other object), burning, or otherwise harming a child whether or not the intention was to hurt the child.
      2. Sexual Abuse. Sexual abuse (which includes exploitation and sexually inappropriate behavior) is engaging a child in sexual activities, including genital or anal contact, that he or she cannot comprehend, is developmentally unprepared for, and cannot give consent for, or violates the law; non-contact abuse such as exposing the child to exhibitionism, voyeurism or sexually explicit material; using the child in pornography; and pandering the child for sex by others. Sexual abuse includes the employment, use, persuasion, inducement, enticement, coercion, or assistance of any person in order to engage in any sexually explicit conduct or simulation of such conduct for the purpose of producing a visual depiction of such conduct; the rape, statutory rape, molestation, human trafficking, or other form of sexual exploitation of children; or incest with children. The sexual activities may include all forms of fondling, oral-genital, genital, or anal contact by or to the child.
      3. Emotional/Psychological Abuse. Emotional/psychological abuse refers to behaviors that harm a child’s self-worth or emotional well-being. Examples include name-calling, shaming, rejection, threatening, and withholding love.
      4. Neglect. The failure of the parent to provide for a child’s basic needs. Neglect may be:
        1. Physical (e.g., failure to provide necessary food or shelter, or lack of appropriate supervision);
        2. Medical (e.g., failure to provide necessary medical or mental health treatment);
        3. Educational (e.g., failure to educate a child or attend to special education needs);
        4. Emotional/Psychological (e.g., inattention to a child’s emotional needs, failure to provide psychological care, or permitting the child to use alcohol or other drugs); and
        5. Abandonment (e.g., the failure of the parent to provide reasonable support and maintain regular contact with the child).
        NOTE: For information on State and Tribal Child Welfare Law and Policy go to:
    5. Disclosure. Disclosure is the process of a child revealing information about their experience with CM. Disclosure about abuse can be directly or indirectly communicated, voluntarily or involuntarily.
    6. Evidence Collection Kit. An Evidence Collection Kit (also known as the Sexual Assault Evidence Collection Kit) is a state-specific kit for the collection of forensic evidence, document history, body maps, biological sample collection, guidance for the examination, treatment, information, and referrals. The adult kit may be modified for pediatric forensic examination and documentation or states may have a specific pediatric evidence collection kit.
    7. Human Trafficking. Human trafficking, for the purposes of this policy, is a form of modern slavery that occurs when a minor is induced to perform forced labor, domestic servitude, or is sexually exploited regardless of the use of force, fraud, or coercion.
    8. Mandated Reporting. Mandated, or mandatory, reporting refers to jurisdictional laws and policies which mandate certain agencies and/or persons in helping professions (teachers, social workers, health staff, etc.) in that jurisdiction to report to child protection and/or criminal justice authorities actual or suspected CM (e.g., physical, sexual, neglect, emotional and psychological abuse, unlawful sexual intercourse). Some jurisdictional laws require all citizens to report child sexual abuse.
    9. Medical Forensic Exam - Pediatric. A medical forensic examination for pediatrics is conducted by a health care provider with specialized education and clinical experience in the collection of forensic evidence and treatment of pediatric patients who have been abused. The examination includes: evaluating the child for acute care needs; gathering information from the child and her/his parent, as appropriate, for the medical history; a physical exam including an anogenital component; coordinating treatment of injuries; documentation of exam findings; collection of forensic samples from the child, when applicable; information, testing, treatment, and referrals for sexually-transmitted diseases [including Human Immunodeficiency Virus (HIV)]; assessment of suicidal ideation and other non-acute medical concerns; and follow-up as needed.
    10. Multidisciplinary Team (MDT). An MDT is a group of individuals from various organizations (e.g., tribal, state, federal, community) who collectively coordinate and communicate with each other in response to a report, disclosure, or suspicion of CM. Team structure provides consistency in acting, messaging, tracking, updating, reviewing, educating and other activities related to the response.

      NOTE: While IHS facilities are not mandated to form MDTs, IHS does require at least one staff member be designated as the point of contact responsible for coordination, collaboration, and communication with existing MDTs, Coordinated Community Response teams, and/or Child Protection Teams.

    11. Parent. A parent, for the purpose of this policy, is a biological parent, legal guardian, foster parent, or other individual who may lawfully exercise parental rights with respect to the child.
    12. Pediatric Sexual Abuse Examiner (PSAE). A PSAE is a health care provider with specialized education and clinical preparation to provide medical forensic care to children.
    13. Prepubescent. Prepubescent is a stage of pubertal development determined by secondary sexual characteristics rather than chronological age. Prepubescence is reflected as stage 1 or stage 2 of the Sexual Maturity Rating Scale; also referred to as the Tanner Scale.
    14. Sexual Maturity Rating Scale. A Sexual Maturity Rating Scale, also known as the Tanner Scale, details the physical signs of breast, pubic hair, and male genitalia development for each of the five sexual maturation stages.
    15. Trauma-Informed Care. Trauma-informed care, as used in this policy, is the provision of care in a manner that recognizes the impact of trauma and prevents re-traumatization.
    16. Victim Advocate. In cases of CM, a victim advocate is a person who assists victims of CM with access to specific services provided by community-based programs, children’s advocacy centers, child protection services, tribal social services, federal programs, and others. These services may include support, crisis intervention, information, referrals, counseling, and advocacy to ensure the child’s interests are represented, their wishes respected, and their rights upheld. In addition, advocacy programs may provide follow-up services, such as support groups, counseling, accompaniment to related appointments, and legal advocacy (civil, criminal) to help meet the needs of children and their families.

      NOTE: The IHS does not employ victim advocates.


  1. Chief Medical Officer. The IHS Chief Medical Officer (CMO) is administratively responsible for the implementation of this policy.
  2. National Forensic Nurse Consultant/Coordinator. The IHS National Forensic Nurse Consultant/Coordinator assists in the implementation of this policy through providing consultation, technical assistance, and linkages to training and resources.
  3. Area Chief Medical Officer. The Area CMO maintains a repository of IHS policies in his/her respective Area, monitors those policies for compliance with this chapter, and submits copies of local policies to the National Forensic Nurse Consultant/Coordinator.
  4. Chief Executive Officer. The Service Unit Chief Executive Officer (CEO) is responsible for:
    1. Ensuring the facility’s CM policy is approved and fully implemented, reviewed, and updated per Area Governing Board procedures;
    2. Ensuring all staff receive annual CM training during orientation and repeated annually [refer to 3-36.9(A)]; and
    3. Signing formal Memorandums of Understanding with tribal or local Child Protection Teams, Multidisciplinary Teams, or related groups, when appropriate, to ensure institutionalized and sustainable participation, coordination, and collaboration by IHS personnel with these outside groups.
  5. Facility Medical/Clinical Director/Chief Medical Officer (CMO). The facility’s Medical/Clinical Director/CMO is responsible for:
    1. Developing and implementing the facility's CM policy and procedures in accordance with the requirements set forth in this policy;
    2. Submitting a copy of the facility’s CM policy to the IHS Area CMO for monitoring compliance;
    3. Establishing standing medication and laboratory orders and order authentication processes for registered nurses practicing as PSAEs;
    4. Designating staff member responsibility for collaboration with groups in tribal communities, including existing MDTs, Coordinated Community Response team, and/or Child Protection Team;
    5. Ensuring medical staff receive required annual CM education and training, and that education and training records are kept for compliance and made available upon request by the Area CMO or National Forensic Nurse Consultant/Coordinator;
    6. Ensuring that health care providers with a pending background investigation are within sight and under the supervision of another staff member (with a satisfactorily completed background investigation) at all times when they are in contact with or have control over an Indian child;
    7. Ensuring medical staff maintain local credentialing and privileging processes for performing CM medical forensic examinations as applicable; and
    8. Implementing a process for quality improvement (QI) and peer review of all CM medical forensic examinations inclusive of medical and nursing staff.
  6. Facility Chief Nursing Officer/Director of Nursing. The facility Chief Nursing Officer/Director of Nursing is responsible for:
    1. Assisting with the development and implementation of the facility’s CM policy and procedures in accordance with the requirements set forth in this policy;
    2. Ensuring that sexual assault nurse examiners with a pending background investigation are within sight and under the supervision of another staff member (with a satisfactorily completed background investigation) at all times when they are in contact with or have control over an Indian child;
    3. Obtaining the necessary equipment and supplies for conducting medical forensic examinations (e.g., digital cameras, tape measures, evidence collection kit supplies, and traditional healing items) for facilities providing this level of care;
    4. Developing forensic nursing staff competencies for PSAE practice;
    5. Ensuring nursing participation in QI process in coordination with the facility medical/clinical director/CMO;
    6. Providing nursing staff the opportunity to attend PSAE didactic and clinical skills training; and
    7. Ensuring all nursing staff receive annual CM training, records are kept for compliance in each facility, and are made available upon request by the Area CMO or National Forensic Nurse Consultant/Coordinator.
  7. Service Unit Behavioral Health Supervisor. The Service Unit Behavioral Health Supervisor is responsible for:
    1. Ensuring behavioral health staff evaluate the needs of CM patients and their parents by providing assessment, counseling, follow-up care, and referrals for specialty care; and
    2. Ensuring behavioral health staff receive required annual CM education and training, and that education and training records are kept for compliance and made available upon request.
  8. Clinical Staff. The Service Unit Clinical Staff is responsible for:
    1. Following mandated reporting requirements for CM to appropriate law enforcement agency and/or state/tribal child protection services;
    2. Obtaining required annual training on topics related to CM;
    3. Obtaining and maintaining education and training as a PSAE for competencies, credentialing, and privileging (as required, refer to section 3-36.9);
    4. Having knowledge of Agency and local policy content and location of policy within facility; and
    5. Notifying his/her supervisor and/or the facility CEO on receipt of a subpoena to testify in court (refer to 3-36.11).


All staff that have regular contact with or control over children must be screened through the Child Care National Agency Check with Written Inquiries for prior allegations of suspected CM as part of the recruitment-and-hiring process. This includes background checks consisting of past employment history, criminal, and child abuse registry (refer to regulations at 42 CFR §§ 136.401-418).


  1. Chaperones should be provided when requested by a patient, parent or caregiver. A support person of the patient’s choosing, such as a parent or caregiver accompanying the child, should also be an option if a chaperone is not desired by the patient.
  2. Chaperones should be offered and supplied by IHS providers if the patient is a child, adolescent, or young adult and the examination requires inspection or palpation of anorectal or genital areas and/or the female breast.
  3. If a provider indicates a medical examination should be conducted with a chaperone present and the patient refuses, the patient or the parent should be given alternatives.
  4. All chaperones must have a favorably adjudicated background investigation on file as required under 25 U.S.C. § 3207 and 34 U.S.C. § 20351.


  1. Reporting Requirements. It is IHS policy that all staff must report child maltreatment immediately, and in all cases within 24 hours, to appropriate law enforcement or child protective services. Facility policy identifies under what circumstances to report, the type of information to report, to whom they should report, the reporting procedures, and the timelines for making a report. All staff are responsible for knowing and complying with the reporting requirements. Facility policy should ensure universal awareness of these requirements among all staff and should identify appropriate local agencies who will receive child maltreatment reports.
    1. Professional staff have licensing standards that require the reporting of suspected CM.
    2. There is no requirement that reports of CM be cleared through service unit administrative channels.
    3. The IHS will not take administrative or other adverse action against anyone who reports a reasonable suspicion of CM in accordance with applicable laws and policy.
    4. If an IHS Health Care Provider is suspected of, or has engaged in, sexual abuse of a child, IHS staff will also follow the reporting requirements outlined in Indian Health Manual, Part 3, Chapter 20, Protecting Children from Sexual Abuse by Health Care Providers. [Refer to 3-20.2 RESPONSIBILITIES]
  2. Federal Law Requirements. Federal laws require many professionals in the health care, mental health, education, child care, and law enforcement fields who work with children in Indian Country as well as on federal lands or in federally operated (or contracted) facilities, to report suspected child abuse.
  3. Legal Consultation. Consult the OGC regional attorney regarding federal, tribal, and state mandated reporting laws for specific issues or concerns.


  1. Health Records. Each facility must follow the national policies for the maintenance, secure storage, and release of health records. The policies are found in the IHM Part 3, Chapter 3 and IHM Part 2, Chapter 7.

    Health records in CM cases are typically requested by investigating entities. All pertinent records (including labs, imaging, photographs, and documentation) are provided to investigative entities as permitted or required by federal law and in accordance with IHS policies and procedures for release of information.

  2. Use of Medical Information. For CM, medical information may be disclosed for law enforcement purposes to the extent permitted or otherwise required by federal law. To the extent permitted by federal law, the information may also be shared in private, interagency, multidisciplinary meetings whenever those meetings are not open to the general public and participants in the meeting are required to keep conference proceedings confidential.
  3. Confidentiality. Reporting suspected CM is an exception to federal privacy requirements, and may be permitted within the confines of applicable federal law.
  4. Consultation for Disclosure. The facility Health Information Management (HIM) Director, CEO, Area HIM Consultant, or OGC regional attorney, as needed, should be consulted when guidance is needed regarding disclosure of health records and applicable laws.


  1. Informed Consent. Informed consent for CM refers to explaining all aspects of the exam process to the patient and her/his parents in a manner they can fully understand and is developmentally appropriate. (For more information, refer to IHM Part 3, Chapter 3 and IHS Risk Management Manual, Chapter 6).

    Informed consent includes a discussion of the following elements:

    1. An explanation of the exam;
    2. Reasonable alternatives to the proposed examination;
    3. Risks, benefits, and uncertainties of the exam;
    4. Rationale for photo-documentation;
    5. Mandatory reporting requirements;
    6. Assessment of understanding, including interpretation services; and
    7. Acceptance of the intervention.
  2. Waiver of Parental Consent. Photographs, x-rays, medical examinations, psychological examinations, and interviews of an Indian child suspected of having been subject to abuse shall be allowed without parental consent if local child protective services or local law enforcement officials have reason to believe the child has been abused; or pursuant to section 3-36.7 C.
  3. Minors. It is the policy of the IHS to follow the law of the state where the IHS facility is located concerning the age of consent. When developing local policy and procedures for CM, any questions regarding this provision must be directed to the OGC regional attorney.

    NOTE: An emancipated minor, as used in reference to the parent-child relationship, are those who live independently of their parents; and involves an entire parental surrender of the right to the care, custody, and earnings of the minor as well as a renunciation of parental duties. The criteria for emancipation varies by state; however, most include court orders, marriage, and financial independence. Emancipation may be expressed, implied, or granted by court petition. Married minors are not required to obtain the consent of a spouse or parent for medical treatment; minor parents may consent to the treatment of their children.


Clinical staff function within their scope of practice when responding to CM, including obtaining the medical history, performing the physical exam, ordering tests, medical forensic exam with or without evidence collection, treating injuries, prescribing medications, and obtaining consultation as necessary.

  1. Entry into the Health Care System. Staff will:
    1. When there is a suspicion of CM, staff completing initial screening/triage will obtain only enough history to inform the health care provider of concern for CM;

      NOTE: Taking a detailed history of injury or abuse should be conducted during the examination portion of the visit to avoid patient having to disclose a detailed history of injury or abuse to multiple health care professionals. The screening or triage chief complaint should be straight-forward with only enough information solicited to determine a triage-level or urgency of time-sensitive exam.

    2. Prioritize care of the child and place the child and accompanying adults in a private area;
    3. Perform a timely medical screening exam;
    4. Distinguish between acute and non-acute need for medical forensic care, and arrange for appropriate exam; and
    5. Facilitate access to a victim advocate (community based, tribal, state, or federal), where available, for children and non-offending parent of children at risk for CM.
  2. Consent for Care. (Refer to section 3-36.7) Clinical Staff will:
    1. Explain the exam process to obtain informed consent;
    2. Tailor the process so it is developmentally and linguistically appropriate for the child and parent; and
    3. Chaperones should be provided when requested by a patient, parent or caregiver.
  3. Examination. Clinical staff will:
    1. Obtain thorough medical history including a full review of systems;
    2. Perform a complete physical exam including the anogenital exam. When there is a disclosure or suspicion for sexual abuse the physical exam is performed by a health care provider with specialized training as a PSAE, either onsite or by referral;
    3. Assess for injury, strangulation, and signs of human trafficking;
    4. Obtain diagnostic studies (labs, imaging);
    5. Incorporate evidence collection, when indicated;
    6. Obtain consultation, as appropriate; and
    7. Where care is provided by referral, consult with health care provider at referral facility, and arrange for transportation to and from the referral facility.

      NOTE: A patient support person is allowed during the examination and may be a parent, staff member, or another supportive person not suspected of involvement in the abuse, and who does not cause additional stress to the child. Law enforcement and child protection services should not be in the exam room during the medical forensic examination.

  4. Evidence. Ensure CM patients receive care from health care providers trained to perform pediatric medical forensic examinations utilizing sexual assault evidence collection kits provided by the state.
    1. Evidence collection is guided by patient presentation and medical history;
    2. Obtain indicated imaging and lab studies; and
    3. Maintain chain of custody and integrity of forensic evidence through secure storage in environmentally appropriate conditions until collected by the appropriate law enforcement agency.
  5. Sexually Transmitted Infections (STI) and Human Immunodeficiency Virus (HIV).
    1. Evaluate for STI/HIV exposure risk.
    2. Use recommended age-appropriate lab tests and treatment per current Centers for Disease Control and Prevention’s Sexually Transmitted Disease Treatment guidelines.
  6. Alcohol and Drugs.
    1. Assess for the use of, or contact with, alcohol or drugs in suspected CM presentations.
    2. Collect toxicology samples, as appropriate.
    3. Document chain of custody for toxicology samples.
  7. Discharge Planning and Referral. Mandated report, referrals, and other follow-up planning may take place at any time during the patient encounter.
    1. Verify that mandated report has been completed.
    2. Safety plan has been addressed.
    3. Medical follow-up arranged, including to referral site when indicated.
    4. Referrals may include behavioral health, social services, counseling, community based advocacy organizations, traditional/cultural healing, faith-based organizations, and other appropriate services.
  8. Documentation.
    1. Document all care provided in the health record including chief complaint, relevant history, medical examination, laboratory and other diagnostic procedures, body maps, photographs, treatment, safety assessment, interventions, follow up plan, and referrals.
    2. Upload and secure all paper and photo-documentation into the health record adhering to privacy requirements.
    3. Contact the HIM Director for release of information request.


  1. Training.
    1. All Staff. All staff are required to receive CM training during orientation and repeated annually (i.e. policy content, mandated reporting, and witnessing abuse).
    2. Clinical Staff. All clinical staff shall participate in one hour of annual CM training (i.e. screening, clinical response, reporting, human trafficking).
    3. Medical Forensic Staff Caring for Pediatric Patients. All PSAE training must conform to the current U.S. Department of Justice National Training Standards for Sexual Assault Medical Forensic Examinations.
      1. Registered Nurses, Advanced Practice Nursing, Physician Assistants: Successful completion of a PSAE education program that grants a minimum of 40 hours OR successful completion of a pediatric/adolescent/adult sexual assault forensic examiner education program that grants a minimum of 64 hours.
      2. Physicians: Successful completion of a minimum of 16 hours of formal didactic training in the medical evaluation of child sexual abuse.
  2. Privileging. Facility privileging policies for advance practice nurses, physician assistants, and physicians conducting pediatric sexual abuse medical forensic examinations must meet training and experience guidance specified in 3-36.9A(3).

    NOTE: SANE-Pediatric certification is not a requirement for practice at IHS-operated facilities.

  3. Competencies for Registered Nurses in the PSAE Role.
    1. Clinical Skills Competency. Direct patient care clinical preceptorship is required for all registered nurses. Clinical preceptorship shall be completed with the guidance of a forensically experienced examiner either onsite, at a high-volume PSAE program, or a simulation clinical skills laboratory setting.

      Competencies for registered nurses to perform pediatric medical forensic exams will be maintained in employee file.

      NOTE: Competency is determined by the professional assessing the required clinical skills.


Facilities must have a system in place for QI of pediatric child maltreatment services including case review for policy compliance and maintenance of staff competency. Onsite PSAE programs must be linked to a peer review process.


For guidance, refer to the Indian Health Manual Part 5, Chapter 27 - Responding to Requests for IHS Employee's Testimony or IHS Documents in Proceedings where the United States is not a Party.

For additional guidance, consult with the OGC regional attorney.